Declare physician affiliation for an ICHSC without retyping credentials

Physicians affiliating with Integrated Community Health Services Centres repeat legal name, CPSO registration, practice address, and ICHSC licensee identifiers on every affiliation authorization. This guide is an example of storing them once in hivi.

Official form and source

Start from the official source and always use the current version — form numbers and links can change:

• Service page: Forms for community surgical and diagnostic centres — ontario.ca
• Form (Central Forms Repository): Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCs — 014-4900-85

What this form is about

Form 014-4900-85 is the Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCs, used when a physician affiliates with an Integrated Community Health Services Centre — confirm ministry requirements on ontario.ca.

Before you start: what to gather

• Physician full legal name and CPSO registration number.
• Practice address and contact phone or email.
• ICHSC licensee legal name and facility identifiers.
• Declaration of professional standing — confirm current attestation wording on ontario.ca.

Confirm the current process on ontario.ca.

How hivi makes it faster

1. Save it once. Store your physician and ICHSC organization names, addresses, and registration numbers in your hivi profile.
2. Keep documents ready. Upload supporting documents to hivi Files so you are not searching at form time.
3. Autofill the form. Use the hivi Chrome extension on a web form, or fill a PDF from your saved profile inside hivi.
4. Review and submit yourself through the official channel.

Why do it in hivi

Related Ontario forms repeat the same personal details. Captured once in hivi — stored in Canada, with AI on its own servers — every form starts mostly complete.